Table 2 Barriers to the implementation of preemptive pharmacogenetic-guided chemotherapy dosing
CFIR Domain | CFIR Construct | Theme | Representative Quotation |
|---|---|---|---|
Intervention characteristics | Evidence strength and quality | Limited evidence base | For therapeutic dose recommendations, I want it to be from NCCN, ASCO, or the Europeans … Anything less than that is weak. (O9) I have no problems with palliative intent … but when we talk about curative, unless we had prospective data, I’d be a little more cautious. (O15) |
Relative Advantage | Questionable impact on clinical care | How often is this really going to change our therapy? ...If we don’t change it, is it a matter of life or death, or is it slight toxicity that we can manage otherwise? (P3) | |
Complexity | Cumbersome and lengthy testing process | If you don’t make it … as easy as a CBC … you may get a start, but somewhere down the road, it will fall off the track. (O12) I don’t – I can’t – do preemptive [PGx testing] because usually when they’re coming to see me, they need to start therapy sometime in the next couple of weeks, and so I’m not going to have a result back to actually do a meaningful assessment. (O1) | |
Outer Setting | Patient Needs & Resources | Lack of alternative therapeutic optionsa | If you don’t have 5-FU for a colon cancer patient, you really are very limited in terms of what you have in your treatment armamentarium, especially if they have a curable disease … (O3) |
External Policies & Incentives | Lack of insurance coverage | I would certainly want to know what, if any, cost or coinsurance was passed down to the patient … I’d be a little bit worried if it turned out that only people with certain types of insurance would be eligible for the testing. (O8) | |
Inner Setting | Access to Knowledge & Information | Challenging PGx test interpretation | Once I had the information, UGT1A1, for instance, I wouldn’t know what to comfortably do with it. (O7) If you’re in a non-academic center and you don’t have other people with expertise in a multidisciplinary fashion, then you’re sort of stuck with a test that you’re not sure what to do with. (O14) |
Characteristics of Individuals | Knowledge & Beliefs About the Intervention | Clinician lack of knowledge | I honestly perceive just a baseline deficiency in my own education around DPYD. (P7) |
Self-efficacy | Remembering to order PGx testing for eligible patients | The prescriber remembering to do it … is always the worst. (P2) |